This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

Friday, 24 September 2010

Another Classic Quote from High Level Nurse

We already had a previous comments post. This new comment wins hands down.

I cannot tell you if the person who said the following is a Matron, a Clinical Lead, a Nurse Specialist, a non ward based Nurse manager etc etc. But she is one of the above.

Like most of the silly commentators mentioned in my previous post she is an older nurse, trained under the old system; she hasn't worked on a ward since 1982 and she HATES Nurses who choose to stay at the front lines providing direct patient care. She sees them as "Nurse Failures". Thank god that us University educated Nurses don't think like that. We are going to be on the wards providing direct patient care until we retire anyway. It is where you start out when you graduate Nursing school and these days it is where you stay as there is NO PROMOTION and recruitment freezes.

She has given the frontline staff nurses even more scores to do. Not content with having them down twice a week she now wants us to do them on all 35 patients every day (irregardless of risk factors) and document the results in 4 different places. Each sheet of paper of course requires the nurse to write the patients name, date of birth, 9000 digit long NHS number on both front and back. There is the waterlow score for pressure areas, the nutrition score, the fall risk score. Blah blah blah. If a patient deteriorates and moves from a low waterlow score to a high one then obviously there is higher risk of pressure area damage and certain actions we will then need to implement. As if we wouldn't realise without the score....eye roll.

We told Nurse Ancient that this amount of writing is ridiculous, physically impossible etc etc. She called on us to ask why her scores were not being done.

When we told her we had too many patients, too many things going on at once and that doing this insane amount of redundant paperwork was impossible and pointless she called us "whingers". And then she said:

"You don't really have to score them every day if you are busy.....just copy down what the last person wrote or make it up...guesstimate....just make DAMN SURE THAT THE DOCUMENTATION IS COMPLETED".

Um. Well what is the point then? If I am going to write all these names, patient info, scores and numbers on 4 different worksheets back and front for 35 people I need to know that it is actually going to benefit the patients.

Still not going to do it. She can bite us. They just had 5 RN's quit simultaneously off the 40 bed even more short staffed hellhole ward below mine. Let's see if we all get sacked for refusing.

Our younger RNs are scared of the Queen Bee "Nurse" quoted on this post. There they are running around, trying to get all this stupid paperwork done so that they are seen as "good nurses" by their "superiors".

Militant Medical Nurse knows that being a good nurse is inversely proportional to being a good employee. Fuck the non essential paperwork, I have patients to nurse. I am trying to teach this notion to the youngsters. Safe patient care first: fucktwittery last...Of course if the hospital gets sued and the paperwork is not 100% complete (including scores) a barrister will use that to nail the trust (and clinicians responsible for patient) to a wall.

29 comments:

Brings to mind 2 related experiences. The 1st in Leicester, the 2nd in Sheffield.

As a health service director of information (and Review!) - 20 years ago - I was asked to help a Nurse Researcher who had difficulty applying an accuity score, to nurse staffing calculations for care of the elderly, as they did not seem to make any sense. After asking a Maths graduate and public health doctor, in my department, to see if he could see why this might be... and getting nowhere, I ran a series of calculations to test the sensitivity of the formulae being used and found that 100% of the difference in required staffing levels - that resulted - could be explained by one variable.

When I asked the researcher what this factor was, she said it was the "correction" that the Chief Nurse said should be applied to acute ward accuity scores for care of the elderly. On closer examination this correction factor was not based on evidence of any kind. As a result I (unhelpfully!) concluded that the Nurse Researcher did not need to collect any future data and should just apply the chief nurse's subjective assessment! This was obviously not practical as the Chief Nurse expected the data to be collected and calculated performed to confirm her judgements - just smoke and mirrors!

A year or so later as a patient on an acute ward in Sheffield I remarked that there seemed to be a lot more nurses on the ward than the previous day. I was told that the previous day everyone was too busy to fill in the forms and as a result staff were moved elsewhere in the hospital, which is why they were all so very busy. So the next day they made sure that the forms were filled in and to their surprise were "rewarded" with more staff when they were not really needed. SO they had time to talk to me about the nonsense of it all.

That is when I truly became aware of the utter futility in trying to score the effect of patient demand on nursing workload as an inverse law operated in getting accurate raw data. This problem is of course exacerbated by fools with an absolute faith in a black box calculation which disguises the fact that it is all subjective guess work masquerading as rational management.

This is a problem that has been allowed to fester for too long and ends up with the situation you have describe. Sadly I can not suggest anything that can be done to bring the fools to their senses..... just don't let them grind you down ...please!

Take a grade 2 sacral ulcer for example. I know that a dressing is required, air mattress & cushion needs to be ordered, patient to have regular positional changes, good nutrition, monitor for infection etc etc...

Anonymous 04:07: It's better (and easier too), to prevent the pressure sore occurring in the first place. After all, to prevent a pressure sore you have to take preventive measures, and you list some of them in your post, but once a sore has occurred you have to take preventive measures plus you have to treat it as well, possibly doubling your work-load. It makes sense to identify patients at risk early and institute preventive care immediately.

My trust refuses to allow the staff nurses to order airbeds and aircushions for the patient unless the patient already has a grade 2.

Many patients all ready come into hospital malnourished.

It can take all 4 of us (two nurses and two health assistants) to turn and reposition everyone that needs it.

That means one move in 4 hours and that is if we ignore every thing else that is going on. Otherwise with will take longer. Remember that acute medicine and care of elderly has been combined so you have both types on patient together.

Documentation is there for one purpose only- to cover your ass. Does filling in the paperwork make you a better nurse? I think most of us would agree that prevention is the best option when talking about pressure sores. Prevention means having enough nurses to ensure that patients are washed and assessed by an RN, assisted with meals as needed and equipment provided as asked for. NOT being fobbed off with the fact that the equipment library does not have any more mattresses (I kid you not) or that MAU should be able to function with 6 trained RNs and a few HCAs/APs for 45 patients. This is the reality of frontline care in the NHS today...a timebomb waiting to go off as more and more RNs leave and head to other countries. Most of our senior nurse managers would not know what to do if a patient was put in front of them and this is what needs addressing. The NMC needs to make it COMPULSORY that to keep your PIN you need to remain clinically active...that goes for nurse educators as well.

Anonymous (6:51) I completely agree that pressure sores should be prevented rather than developing in the first place. I think every nurse knows that pressure sores are caused by poor nursing and I personally find it very shameful when a patient under my care gets one.

Pressure sores can easily be prevented by early identification, adequate staffing and simple measures.

Unfortunately adequate staffing simply does not exist on most wards and as a result patients do not get repositioned as often as they should. Also many patients have pressure sores prior to admission and what about patients who refuse to be turned, despite explanation of the risks?

I guess the point I was originally trying to make is that there is far too much documentation and that my time would be better spent with the patient.

What I would like to know and no one important has ever explained it to me is that, why, when Drs are probably the most litigated against profession in the country do they manage to defend themselves from often one line in a pts notes whereas we are expected to write the equivalent of war and peace in triplicate each time a pt farts. Fuckwittery of the first degree

Is there REALLY a nurse anywhere who needs to do a waterlow, a nutrition assessment, a mobility assessment, etc, etc to be able to recognise which patients are at risk for pressure damage?? Is there REALLY a nurse anywhere who doesn't know this just by looking at the patient??? For God's sake, just give me the time and the staff to look after my patients properly and give me the authority to order an air mattress when I see fit.

I honestly can only remember ONE time when I was surprised that a particular patient developed a pressure ulcer, and this patient did not score as "high risk" using all the wonderful screening and assessment tools that the powers that be require us to fill out endlessly.

You ask: "Is there REALLY a nurse anywhere who needs to do a waterlow, a nutrition assessment, a mobility assessment, etc, etc to be able to recognise which patients are at risk for pressure damage??"

I reply, of course not. Or, more specifically, I reply that any nurse who NEEDS to use these methods should probably consider looking for another job, preferably one that requires no mental effort. I would say that, in my opinion, the whole assessment tool industry is more or less useless.

If you read my post again you may note that I made no reference to Waterlow or any other such assessment system. On the other hand, I hope you would not disagree with my statement that early identification of patients at risk of suffering complications is essential. I would agree with you that a nurse should not need to fill in forms to identify such patients. Once identified, as you say, such patients should be cared for appropriately.

As far as I am concerned the only documentation necessary should be a simple expression of professional judgement on the lines of "This patient is at risk of ... because of... and requires the following care/ nursing equipment."

"statement that early identification of patients at risk of suffering complications is essential"

It is essential and it is of course in our heads and on our minds. Yet early identifaction isn't helping.

Early identification works when you have enough uninterrupted time to assess and get to grips with a patients situation, enough boots on the ground to position people, provide nutrition and it works when the Trust allows you to have the equipment that you need (i.e. airbeds).

I am a Clinical Lead somewhere in Englandshire. I find this blog informative, funny but worryingly true.I would never leave my ward understaffed, and frequently attend to deal hands on with clinical issues that arise. The paperwork comments I can see both sides of, from a personal perspective (excellent documentation saving my ass) to the other side - having to conduct investigations and seeing piss poor standards leaving nurse wide open.We do not support each other as we should, too bothered earning brownie points and pretending we are doctors.... The NMC and RCN are both wastes of time that drain our finances and offer little in the realms of support or solidarity to our plight.Trusts have frozen posts, to find 'surplus cash' to be spent on pictures and prettt chairs. I would rather employ the excellent student nurses whom have qualified but we are loosing to the private sector.We can't / don't strike. I wonder if the worm will ever turn and we develop a little more chutzpah like our American counterparts. It disappoints me that as you climb the ladder there is a real distancing from what happens on the shop floor. Whilst I feel desperately for your plight, not all senior nurses behave in this way (I have refused to conduct useless audits and do not attend useless meetings).I have introduced your blog to many of my collegues. Keep up the excellent work - from a non - degree trained back in the arc nurse...

The NMC is run by a bunch of hysterical lesbians who rather than defending our profession in return for the ridiculous amounts of money they charge us each year are more content with stabbing us in the back

If only it were the case that we could write that one line you propose: "This patient is at risk of ... because of... and requires the following care/ nursing equipment."

I also agree with the poster who pointed out that the busier (and more understaffed) we are, the poorer the documentation is - we're so busy actually caring for the patient that we don't have the time to prove we cared for the patient. I can see where this is a problem but it's also true, as Nurse Neil said, that doctors can write "improving" and everyone will accept that the patient is improving. I wonder why it's different for us?

I have never suggested degree trained nurses pretend to be doctors, my comment was aimed at those who climb the corporate ladder and distance themselves from the art and science of nursing. I know many old style and new style who fit this unfortunately. I most certainly agree that non-clinically based staff should spend at least a week per year on the shop floor to maintain registration....

Oh for the days when you could write "care as planned" and it was taken as read that you had done just that. As a senior nurse myself ( manager really but I don't like the title as many of my managerial colleagues stay away from the wards) I am also fighting against the tide of useless audit. We will also have yet another set of students who qualify and have to look elsewhere for jobs as the Trust wants to save money. Staffing levels are a joke and I am sick and tired of trying to make the egits understand just why Mrs X or Mr Y needs a particular dressing/piece of equipment/drug that is not normally on our unit (so will have to be ordered and PAID for). Every shift that I opt to work on the floor is a shift that is used as a weapon by the powers that be to try and undermine me. They do not want managers that stay clinically active as then we get to see first hand where things are going wrong. As for the NMC and the RCN...I cannot think of a single positive thing to say about them- so, as my mother used to say...if you can't say anything good....

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In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.